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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
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New procedure for submitting letters

  • Patricia Casey and Jonathan Pimm
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Scottish Survey of Prescribing Benzodiazepines in Benzodiazepine Dependence

Michael William Turner, ST5 General Adult Psychiatry, NHS Grampian
Seonaid Anderson, Consultant Addiction Psychiatrist, NHS Grampian
20 November 2018

It is estimated that 0.69% of patients at GP surgeries in the UK are classed as long term benzodiazepine users [1]. As there appears to be a steady increase in the length of benzodiazepine prescribing, it may be that benzodiazepine dependence is becoming a larger problem [2]. The population of individuals who have become dependent on benzodiazepines is clearly diverse, from young multi-substance abusers who may purchase diverted supplies, to the elderly who may have been on a night time dose for over a decade. Its individuals from the former group that often cause anxiety in practitioners, where the quantity and type of benzodiazepine consumed is often unknown.

We created a survey composed of ten questions in an attempt to assess specialist clinician’s views on benzodiazepine prescribing in benzodiazepine dependence, as well as examining people’s practices in this situation. The survey was distributed to 119 recipients on the Scottish Association of Addictions Specialists’ mailing list. The survey was distributed on 1st August 2018, and closed on Friday 17th August. For questions where an open text response was requested, answers were reviewed and grouped together in re-occurring themes. Results were presented to the Scottish Association of Addiction Specialists on 7th September 2018 in Stirling.

There was an overall 51.0% response rate. 53.3% of responders were consultant psychiatrists. 20% were specialty doctors and the remainder were general practitioners, associate specialists, and trainee psychiatrists. 27.9% worked for NHS Greater Glasgow and Clyde, followed by 13.1% working in NHS Grampian. Responses were also received from people working in NHS Ayrshire and Arran, NHS Forth Valley, NHS Lothian, NHS Highland, NHS Tayside, NHS Borders, NHS Fife and NHS Lanarkshire. There were also a few responses from retired and locum practitioners.

78.7% of people who responded would prescribe benzodiazepines in benzodiazepine dependence, and 21.3% would not. Those who would not prescribe were distributed across 8 different health boards, with 7 consultants, 3 specialty trainees/registrar psychiatrists, 2 specialty doctors and one general practitioner. Of those who would prescribe benzodiazepines, 89.8% would require a history, 69.4% a drug screen and 57.1% a drug use diary. Other requirements mentioned were a motivation to change (22.4%), good engagement with services (18.4%) and a diagnosis of benzodiazepine dependence (8.3%). 100% favoured Diazepam as their benzodiazepine of choice, if starting in those with benzodiazepine dependence.

52.0% of people using benzodiazepines in benzodiazepine detox opted for a maximum starting dose of 20 to 30mg Diazepam equivalent. 6.0% would start 0 to 10mg and 16.0% would start 10mg to 20mg. 24.0% would use doses of 30 to 40mg. 1 participants would use up to 80mg, but stated that this was only in an inpatient context.

In terms of initial dispensing 76.0% would prescribe daily dispense. 12.0% opted for consume on premises, 8.0% weekly dispense, and no-one would prescribe monthly. 1 person said they would only provide as an inpatient and another said they would align this with their methadone dispensing.

70.0% would be prescribing with the intent to reduce. 6.0% prescribe with the intent of maintenance prescribing. 24.0% preferred to document their own practice, with the majority of these individuals stating it depended on the clinical picture.

All participants - those who prescribe and those who don’t - were asked what guidelines they used for people in benzodiazepine dependence. 49.0% primarily used local guidelines, 31.4% used the “orange” guidelines (Drug misuse and dependence: UK guidelines on clinical management), and 19.6% used either a combination or other resources such as the Royal College of General Practitioner guidance, British Association for Psychopharmacology guidelines, Ashton manual, the Maudsley or just clinical experience.

The last question asked what other treatments you would consider in benzodiazepine dependence. 56% of responders to this question suggested psychological input. Several replies however noted that referrals were often rejected, and that at times patients failed to engage. 34% mentioned psychosocial interventions and 26% noted alternative medications. 12% suggested that the underlying illnesses should be treated appropriately, 4% would optimise opiate replacement therapy and 4% would provide psychoeducation.

The practice of prescribing benzodiazepines, as well as choosing not to, was not limited to a particular health board and can therefore not be

explained by local policy. Those who did not prescribe benzodiazepines in this situation came from eight separate health boards. They were also a mix of professions and grades, including a GP, Consultants, specialty doctors and speciality trainees/specialist registrars. Experience can differ between these titles, however it can be assumed that since different consultants disagreed on whether benzodiazepines should be prescribed, experience may not be relevant to this decision.

It is clear that opinion is divided when it comes to prescribing benzodiazepines in benzodiazepine dependence. Unfortunately, clinicians feel that when it comes to practice in this area, there is a distinct lack of evidence. This obviously contributes to a variation in practices. Some may believe that not prescribing, with a lack of evidence, would be the most medico-legally responsible. However it may be that this attitude is avoiding benzodiazepine dependence rather than engaging with it, and with some guidance supporting benzodiazepine prescribing in dependence this issue can be tackled with more confidence.

1 Davies J, Rae TC, Montagu L. Long-term benzodiazepine and Z-drugs use in the UK: a survey of general practice. Br J Gen Pract, 17 July 2017.

2 J.C. Farias, L. Porter, S. McManus, et al. Prescribing patterns in dependence forming medicines. Public Health Research Consortium, London, 2017.
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Conflict of interest: None declared

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Latest Developments in ADHD

Dr Mukesh Kripalani , Frcpsych, Rcpsych
12 October 2018

Latest updates on ADHD 2018

Attention Deficit Hyperactivity Disorder (ADHD) and Attention Deficit Disorder (ADD) remains a controversial area for clinicians and patients across the world and the UK, despite evidence of effective treatment options and the likelihood of lives being changed for the better.

The National institute for health and care excellence (NICE) in the UK, have recommended interventions since 2006 and recently updated its latest guidance on diagnosis and management in March 2018 ( They have made certain changes to past recommendations which include a suggestion of using Elvanse as first line in adult clients and introducing new safeguards in terms of specific cardiovascular assessment requirements in certain circumstances.

The prevalence of this condition varies across the world and one estimate suggest 5% of school-age children could suffer from the same with a significant cost burden to society ( With persistence of ADHD symptoms estimated in to adulthood to be about 60% ( ), it is imperative the clients are supported and clinicians are familiar with the phenotype and able to appropriately manage the significant co-morbidity that exists with ADHD/ADD ( ).

In a recent article by Sudha Raman et al in the Lancet, trends in attention-deficit hyperactivity disorder medication use was explored in 13 countries and one Special Administrative Region (DOI: They noted the prevalence of ADHD medication use among children and adults increased over time in all countries and regions, but large variations in ADHD medication use in multiple regions exist. They recommended evidence-based guidelines need to be followed consistently in clinical practice and Samuele Cortese and Daniel Cogill ( suggesting no increase in prevalence rates if standard criteria are used.

In a major lancet article ( Samuele Cortese and co, looked at the comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults via a systematic review and network meta-analysis.


I take this opportunity to highlight that pharmacological interventions are safe and is well tolerated across the world and use of stimulants is gradually increasing across the globe. The risks with stimulants medication are usually hyped up but it is exceptionally safe though the risk of diversion remains ( ). The latter could be minimised easily by close supervision and use of long acting stimulants. It is important clinicians recognise this phenotype and direct clients to help as soon as possible as early intervention can change the trajectory of life ( ). The effect sizes clearly demonstrate benefits and the NICE guidelines seem to be consistent with latest meta analysis.

Of course there are co-morbid conditions co-existing which can mask the presence of ADHD and the fact of getting prescribed stimulants is difficult in certain situations to accept.

Hence instead of vilifying ADHD, we should encourage both clients and clinician to embrace the need for immediate treatment (biological, psychological and social) and hence improve outcomes for the future and help clients reach their full potential ( )

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Conflict of interest: None declared

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Trials and Tribulations of S49 orders

Ilyas Mirza, Consultant Psychiatrist, Barnet Enfield and Haringey Mental Health NHS Trust
Mukesh Kripalani, Consultant Psychiatrist, Barnet Enfield and Haringey Mental Health NHS Trust
12 October 2018

The Mental Capacity Act, 2005 (MCA, 2005) is an Act of the Parliament, applying to England and Wales,that provides a legal framework for acting and making decisions on behalf of adults who lack the capacity to make particular decisions for themselves (MCA, 2005). Under section 49 (pilot order) of the MCA 2005, launched in 2016, the Court of Protection can order reports from NHS health bodies and local authorities, when it is considering any question relating to someone who may lack capacity and the report must deal with ‘such matters as the court may direct’. This change has caused significant ethical challenges for psychiatrists.

With regard to professional implications, Section 49 reports require an opinion, which according to the British Medical Association (BMA) and the General Medical Council (GMC) guidance this falls under expert witness work. The recent Pool Judgement is a reminder that the GMC is likely to consider fitness to practice is impaired if a doctor acts outside what is considered their scope of work (Pool v General Medical Council[2014]). The order is usually accompanied by an instruction letter containing legal precedents and a bundle sometimes containing conflicting assessments. Responding to such instructions require medico-legal training and experience in giving opinions to complex questions such as capacity to consent to sex, or consent to drink. We would argue that there is blurring of boundaries between expert and professional witness. There is a need to clarify what legal safeguards that are in place for the author of Section 49 reports, if their opinion is challenged, as it was in the Pool case.

In relation to patient care, the introduction of an automatic right to a medico-legal report, which was previously funded from elsewhere has shifted the cost on to the NHS. Given mental health services are still block funded; more work without additional funding leads to dilution of quality of care elsewhere in the system, hence affecting patient care. Lack of parity of esteem between physical and mental health funding makes this work an onerous burden. Increased workload without remuneration has an adverse effect on staff morale, thereby influencing recruitment and retention within an already struggling NHS.

There is an urgent need to quantify impact on these orders on services. The Royal College of Psychiatrists, working together with NHS England and the BMA, need to define medico legal work could be safely done within existing resource. Moreover, the BMA, GMC, the College and NHS Employers need resolve the discrepancy between what is considered expert witness work by regulatory bodies, being framed as normal NHS work by the Court of Protection (GMC, 2013). Legal safeguards need to be in place if NHS professionals become subject to legal challenge e.g. from an aggrieved solicitor. Consideration needs to be given to a fresh legal challenge if it is evident that this pilot order is affecting patient care.


Court of Protection Transparency Pilot: Case management S.49 pilots extension. 27th July 2017. Courts and Tribunal Judiciary

General Medical Council (2013) Good medical practice London, GMC

Mental Capacity Act (2005) Code of Practice (2007) London: TSO.

Pool v General Medical Council(2014) EWHC 3791 Admin.

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Conflict of interest: None declared

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Choose Psychiatry, Continue Psychiatry

Andrew Howe, ST 4 in General Adult Psychiatry, South London and Maudsley NHS Foundation Trust
Vivienne Curtis, Consultant Psychiatrist
13 September 2018

Could improving oncall experience be the key to trainee retention?

Alongside encouragement to “Choose Psychiatry” we need to consider retention and “Continuing Psychiatry”. A recent survey by the Royal College 1 found that management on-call work was affecting morale so much that some trainees considered resignation. The same report commented on a high attrition rate between core and higher training, citing on call issues as a factor. Out of hours work is a challenging part of working in healthcare. Unsocial working hours can put a strain on the work life balance2, particularly with those who have families.3 The recent junior doctor strikes and new contract highlighted the value junior doctors place on appropriate management of on call work4 and GMC NTS results often highlight difficulties with out of hors working. With psychiatry recruitment in its present state and the concerted effort to increase applications to training via “Choose Psychiatry”, the nature of the on call experience may be the key to ensuring trainee retention. It is important, therefore, to ensure that experience on call is positive, supported and reflects training goals. We would suggest that the involvement of junior doctors in service design and restructure helps to secure this.

This approach was taken within our trust (South London and Maudsley NHS Foundation Trust) during the creation of a new service, the Centralised Place of Safety. This six-bedded unit was opened in June 2017. It is staffed by a dedicated MDT 24 hours and seven days a week. It accepts section 136/135 patients as part of the South London Crisis care pathway. Given its out of hours operation, an on-call medical staffing rota had to be created. The trust involved junior doctors in this process in collaborative way, through discussion with trainee committees and representatives to ensure their educational needs were met. An emphasis was put on face to face supervision by higher trainees with core trainees. Core trainees also had a clearly defined role within the MDT. A subsequent survey of trainees found that they preferred their on-call work in the place of safety compared to other locations5. A quote from the survey of particular note was “I would not want to qualify as a registrar without having had such experience’.

Choice of training scheme is multifactorial and improving on call experience maybe a small but important factor. We feel our service and its design process represent a good example of how to meet trainees needs and, thus, reinforces the need for consideration of trainee experience when planning out of hours rotas. We would argue that retention needs to be prioritised as much as recruitment if the gains of the “Choose Psychiatry” campaign are to be maintained.

1. Till A, Milward K, Tovey M, et al. Supported and Valued? A trainee-led review into morale and training within psychiatry. London, 2017.

2. Karhula K, Puttonen S, Ropponen A, et al. Objective working hour characteristics and work–life conflict among hospital employees in the Finnish public sector study. Chronobiol Int 2017; 34: 876–885.

3. Tucker P, Brown M, Dahlgren A, et al. The impact of junior doctors’ worktime arrangements on their fatigue and well-being. Scand J Work Env Heal 2010; 36: 458–465.

4. Tucker P, Byrne A. The new junior doctors’ contract: an occupational health and safety perspective. Occup Med (Chic Ill) 2016; 66: 686–688.

5. Howe A, Curtis V. What is the educational benefit of being on call ? A review of the on-call experience of psychiatry trainees in a new health based Place of Safety. In: Royal College of Psychiatrists International Congress. Brimingham, 2018.

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Conflict of interest: None declared

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Acceptability of receiving physical health investigations in the Clozapine clinic: a qualitative analysis of patients and healthcare professionals

Jason Hancock, ST7 Psychiatry/ Honorary Clinical Lecturer, Devon Partnership Trust
Chris Dickens, Professor of Psychological medicine, University of Exeter
Julia Frost, Senior Lecturer in Health Services Research, University of Exeter
13 September 2018

Early identification of physical health co-morbidities for people with serious mental illness is an important aim within the Mental Health Taskforce’s five year forward view for mental health[1]. In an attempt to achieve this a number of physical health ‘clinics’ have been developed within the secondary care mental health setting[2]. However there remains a lack of clear evidence regarding how to best structure such services[3] and it is unclear if patients and healthcare professionals (HCPs) find receiving physical health monitoring and investigations in this setting acceptable[2].

Following patient involvement sessions and meetings with local clinical stakeholders, we incorporated basic annual physical health monitoring and investigations (including blood tests and ECGs) into an established secondary care Clozapine community clinic. This intervention was initiated in September 2015 and over the first year offered to 52 out of 80 patients attending the clinic.

We undertook a qualitative study to elicit views from patients and HCPs regarding the acceptability of this intervention. We approached patients who had been exposed to the intervention over the previous year, and HCPs with first-hand experience of the intervention including medical and non-medical staff from the primary and secondary care setting.

Interview schedules were developed by the study team with input from patients attending the clinic. The lead author (JH) undertook 12 semi-structured qualitative interviews between November and December 2016 interviewing 4 patients and 8 HCPs. Interviews lasted between 12 and 30 minutes and were recorded, transcribed verbatim and analysed using the framework approach.

All of those interviewed described the intervention as acceptable. A number of key themes appeared to be underpinning this view. This included HCP perception that the intervention allowed more holistic care. This was particularly the case for secondary care nursing staff:

‘…as much as it is tiring and very busy, you feel that you are doing a bit more for people ... so, the more we focus on physical health it can affect their mental health’ (secondary care nurse).

HCPs also perceived that acceptability was influenced by the strength of existing relationships between patients and secondary HCPs. This view was shared by patients:

‘It’s you know, a personal service….....there's changes I need to make, so they just try and keep me in a positive frame of mind for it, which is appreciated because I need all the help I can get’ (patient).

However HCP in particular raised several concerns regarding the intervention. This included a concern that poor communication between primary and secondary care could result in duplicated investigations:

‘We get, you know, tens of results every day, and the last thing you want if you've already done the HbA1c, err, say a month ago is another HbA1c from the Clozapine clinic (laughs)’ (GP).

Finally a concern was also raised that there remains unclear professional accountability regarding who ultimately hold responsibility for acting upon those investigations requested:

‘I guess I was kind of trained with the idea that if you request a result you act on the result. But I guess perhaps, err, needs to just be tightened up a bit, is ... is ... is still the kind of who acts on the results, how do we know someone's acted on the result’ (Psychiatrist).

While it may be possible to develop an intervention to bring physical health monitoring and basic investigations into the secondary care mental health setting that is acceptable to patients and HCPs further modifications to this model are required. This includes a need to better develop systems to share clinical information and reduce the risk of duplicated investigations, and procedures to ensure consistent and timely interpretation of physical health investigations. In time improved commissioning of physical health services for people with mental illness would provide clarity regarding the clinical roles of primary and secondary care and to determine where financial responsibility for this care lies.

This research was approved by the South West - Exeter NHS Research Ethics Committee (16/SW/0265). Consent was obtained from all participants prior to interviews being conducted. This study was undertaken as part of an Academic Clinical Fellowship for JH funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Funding for the transcription of interviews was provided by Devon Partnership Trust.

1. The Mental Health Taskforce. The Five Year Forward View For Mental Health. The Mental Health Taskforce, 2016. Available at: (accessed 19 Jul 2017).

2. NHS England. Improving the physical health of people with serious mental illness: a practical toolkit. NHS England, 2016. Available at: (accessed 19 Jul 2017).

3. Tosh G, Clifton A, Xia J, White MM. Physical health care monitoring for people with serious mental illness. Cochrane Database of Syst Rev 2014. doi:10.1002/14651858.CD008298.pub3.

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